Arch Dis Child 93:23-29 doi:10.1136/adc.2006.095471
  • Original article

Can Western developmental screening tools be modified for use in a rural Malawian setting?

  1. M J Gladstone1,
  2. G A Lancaster2,
  3. A P Jones3,
  4. K Maleta4,
  5. E Mtitimila5,
  6. P Ashorn6,
  7. R L Smyth6
  1. 1
    Department of Paediatrics, College of Medicine, Blantyre, Malawi
  2. 2
    Postgraduate Statistics Centre, Department of Mathematics and Statistics, Lancaster University, Lancaster, UK
  3. 3
    Centre for Medical Statistics and Health Evaluation, University of Liverpool, Liverpool, UK
  4. 4
    Department of Community Health, College of Medicine, Blantyre, Malawi
  5. 5
    Department of International Health, University of Tampere Medical School, Finland and Department of Paediatrics, Tampere University Hospital, Finland
  6. 6
    Institute of Child and Reproductive Health, University of Liverpool, Liverpool, UK
  1. Dr Melissa Gladstone, Institute of Child Health, University of Liverpool, Royal Liverpool Children’s Hospital, Eaton Rd, Liverpool L12 2AP, UK; mgladstone{at}
  • Accepted 4 March 2007
  • Published Online First 22 March 2007


Objective: To create a more culturally relevant developmental assessment tool for use in children in rural Africa.

Design: Through focus groups, piloting work and validation, a more culturally appropriate developmental tool, based on the style of the Denver II, was created. Age standardised norms were estimated using 1130 normal children aged 0–6 years from a rural setting in Malawi. The performance of each item in the tool was examined through goodness of fit on logistic regression, reliability and interpretability at a consensus meeting. The instrument was revised with removal of items performing poorly.

Results: An assessment tool with 138 items was created. Face, content and respondent validity was demonstrated. At the consensus meeting, 97% (33/34) of gross motor items were retained in comparison to 51% (18/35) of social items, and 86% (69/80) of items from the Denver II or Denver Developmental Screening Test (DDST) were retained in comparison to 69% (32/46) of the newly created items, many of these having poor reliability and goodness of fit. Gender had an effect on 23% (8/35) of the social items, which were removed. Items not attained by 6 years came entirely from the Denver II fine motor section (4/34). Overall, 110 of the 138 items (80%) were retained in the revised instrument with some items needing further modification.

Conclusions: When creating developmental tools for a rural African setting, many items from Western tools can be adapted. The gross motor domain is more culturally adaptable, whereas social development is difficult to adapt and is culturally specific.


  • Funding: Funding was supplied by the Academy of Finland, the Foundation for Paediatric Research in Finland, the Medical Research Fund of Tampere University Hospital, the Alexander Wernher Piggot Memorial Trust and the EWG Memorial Trust. There was no involvement from the study sponsors in the study design, collection, analysis, interpretation, writing of reports or decisions to submit.

  • Competing interests: None.

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